1
|
Lokugamage AU, Rix EL, Fleming T, Khetan T, Meredith A, Hastie CR. Translating Cultural Safety to the UK. J Med Ethics 2023; 49:244-251. [PMID: 34282043 DOI: 10.1136/medethics-2020-107017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The 'Black Lives Matter' movement has exposed structural racism's contribution to these health inequities. 'Cultural Safety', an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be 'culturally safe'. The ways in which New Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the 'nuts and bolts' of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation.
Collapse
Affiliation(s)
- Amali U Lokugamage
- Department of Clinical and Professional Practice, University College London Medical School, London, UK
- Department of Women's Health, Whittington Health NHS Trust, London, UK
| | - Elizabeth Liz Rix
- Faculty of Health, Southern Cross University, Gold Coast Campus, Bilinga, Queensland, Australia
| | - Tania Fleming
- School of Midwifery, Auckland University of Technology, Auckland, New Zealand
| | - Tanvi Khetan
- University College London Medical School Alumni, University College London, London, UK
| | - Alice Meredith
- University College London Medical School Alumni, University College London, London, UK
| | - Carolyn Ruth Hastie
- Department of Nursing and Midwifery, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| |
Collapse
|
2
|
Byju AS, Mayo K. Physician unionisation in the USA: ethical and empirical considerations and the free-rider problem. J Med Ethics 2021; 47:697-700. [PMID: 33115856 DOI: 10.1136/medethics-2020-106668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 06/11/2023]
Abstract
While American physicians have traditionally practised as non-unionised professionals, there has been increasing debate in recent years over whether physicians in training (known also as interns, residents or house staff) are justified in unionising and using collective action. This paper examines specific ethical criteria that would permit union action, including a desire to ameliorate patient care as well as the goal of improving the conditions of working physicians. We posit that traditional rebuttals to physician unionisation often lean on an infinite conception of a doctor's energies and obligations, one that promotes burnout and serves to advance the financial motives of hospital management and administration. Furthermore, this paper explores the empirical justifications for collective action, which include substantial reductions in medical error. Finally, we address the free-rider problem posed by non-union physicians who might benefit from working improvements garnered through union action. We conclude that in order to maintain a notion of justice as fairness, resident physicians who benefit from union deliberations are impelled to acquire union membership or make a commensurate donation and that the healthcare organisations for which they work ought to share in the responsibility to improve patient care.
Collapse
Affiliation(s)
- Arjun S Byju
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Kajsa Mayo
- University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York, USA
| |
Collapse
|
3
|
Cole R, Stone M, Ruck Keene A, Fritz Z. Family members, ambulance clinicians and attempting CPR in the community: the ethical and legal imperative to reach collaborative consensus at speed. J Med Ethics 2021; 47:650-653. [PMID: 33060185 PMCID: PMC8479729 DOI: 10.1136/medethics-2020-106490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/20/2020] [Accepted: 08/25/2020] [Indexed: 06/11/2023]
Abstract
Here we present the personal perspectives of two authors on the important and unfortunately frequent scenario of ambulance clinicians facing a deceased individual and family members who do not wish them to attempt cardiopulmonary resuscitation. We examine the professional guidance and the protection provided to clinicians, which is not matched by guidance to protect family members. We look at the legal framework in which these scenarios are taking place, and the ethical issues which are presented. We consider the interaction between ethics, clinical practice and the law, and offer suggested changes to policy and guidance which we believe will protect ambulance clinicians, relatives and the patient.
Collapse
Affiliation(s)
- Robert Cole
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill, UK
| | | | | | - Zoe Fritz
- THIS institute (The Healthcare Improvement Studies Institute), University of Cambridge School of Clinical Medicine, Cambridge, UK
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
4
|
Knight JK, Fritz Z. Doctors have an ethical obligation to ask patients about food insecurity: what is stopping us? J Med Ethics 2021; 48:medethics-2021-107409. [PMID: 34261802 PMCID: PMC9554025 DOI: 10.1136/medethics-2021-107409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/28/2021] [Indexed: 05/03/2023]
Abstract
Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions (on both individual and public health policy levels) frequently focus on facilitating 'healthy choices', with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours (eg, smoking and alcohol use), as well as with doctors' frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians' ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities.
Collapse
Affiliation(s)
- Jessica Kate Knight
- Department of Acute Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Zoe Fritz
- Department of Acute Medicine, The Healthcare Improvement Studies Institute, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
5
|
Rodger D. Why we should stop using animal-derived products on patients without their consent. J Med Ethics 2021; 48:medethics-2021-107371. [PMID: 34103364 DOI: 10.1136/medethics-2021-107371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/14/2021] [Indexed: 06/12/2023]
Abstract
Medicines and medical devices containing animal-derived ingredients are frequently used on patients without their informed consent, despite a significant proportion of patients wanting to know if an animal-derived product is going to be used in their care. Here, I outline three arguments for why this practice is wrong. First, I argue that using animal-derived medical products on patients without their informed consent undermines respect for their autonomy. Second, it risks causing nontrivial psychological harm. Third, it is morally inconsistent to respect patients' dietary preferences and then use animal-derived medicines or medical devices on them without their informed consent. I then address several anticipated objections and conclude that the continued failure to address this issue is an ethical blind spot that warrants applying the principles of respect for autonomy and informed consent consistently.
Collapse
Affiliation(s)
- Daniel Rodger
- Institute of Health and Social Care, London South Bank University, School of Allied and Community Health, London SE1 0AA, UK
| |
Collapse
|
6
|
Delgado J, Siow S, de Groot J, McLane B, Hedlin M. Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond. J Med Ethics 2021; 47:medethics-2020-106764. [PMID: 33762300 PMCID: PMC7992383 DOI: 10.1136/medethics-2020-106764] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 05/25/2023]
Abstract
This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.
Collapse
Affiliation(s)
- Janet Delgado
- NICU, University Hospital of the Canary Islands, La Laguna, La Laguna, Spain
- University Institute of Women's Studies, University of La Laguna, La Laguna, Spain
| | - Serena Siow
- Department of Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Janet de Groot
- Department of Psychiatry, Oncology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Brienne McLane
- Department of Psychiatry, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Margot Hedlin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
7
|
Salwi S, Erath A, Patel PD, Kaur K, Mitchell MB. Aligning patient and physician views on educational pelvic examinations under anaesthesia: the medical student perspective. J Med Ethics 2020; 47:medethics-2020-106473. [PMID: 32958692 DOI: 10.1136/medethics-2020-106473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 06/11/2023]
Abstract
Recent media articles have stirred controversy over anecdotal reports of medical students practising educational pelvic examinations on women under anaesthesia without explicit consent. The understandable public outrage that followed merits a substantive response from the medical community. As medical students, we offer a unique perspective on consent for trainee involvement informed by the transitional stage we occupy between patient and physician. We start by contextualising the role of educational pelvic examinations under anaesthesia (EUAs) within general clinical skill development in medical education. Then we analyse two main barriers to achieving explicit consent for educational pelvic EUAs: ambiguity within professional guidelines on how to operationalize 'explicit consent' and divergent patient and physician perspectives on harm which prevent physicians from understanding what a reasonable patient would want to know before a procedure. To overcome these barriers, we advocate for more research on patient perspectives to empower the reasonable patient standard. Next, we call for minimum disclosure standards informed by this research and created in conjunction with students, physicians and patients to improve the informed consent process and relieve medical student moral injury caused by performing 'unconsented' educational pelvic exams.
Collapse
Affiliation(s)
- Sanjana Salwi
- Medical Ethics Law and Policy Student Group, Vanderbilt University, Nashville, TN, USA
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alexandra Erath
- Medical Ethics Law and Policy Student Group, Vanderbilt University, Nashville, TN, USA
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Pious D Patel
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karampreet Kaur
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Margaret B Mitchell
- Medical Ethics Law and Policy Student Group, Vanderbilt University, Nashville, TN, USA
- School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
8
|
Carris NW, Cheon B, Wolfson J. Open data, trials and new ethics of using others' work. J Med Ethics 2020; 47:medethics-2019-105898. [PMID: 32709755 DOI: 10.1136/medethics-2019-105898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 05/04/2020] [Accepted: 05/31/2020] [Indexed: 06/11/2023]
Abstract
Data and ideas are the capital of research productivity. Is it ethical to preempt the publication of another researcher's unpublished data or preliminary analysis, perhaps without citation? The long-established answer is 'certainly not'-but recent 'open data' use suggests otherwise. A research competition was held using data from The Systolic Blood Pressure Intervention Trial (SPRINT). This SPRINT Data Analysis Challenge created a novel environment for using open data as data became open early. This allowed third-party researchers the opportunity to assess some of the trial's outcomes before trialists. Could this infringe on trialists' right to analyse their data? Simultaneously, trialists had access to analyses from submissions to the competition that were not formally 'published' with a typical author credit or citation. Therefore, trialists had the opportunity to view the competition submissions and published on those ideas first without a typical way to cite the source of that idea. Could this infringe on researchers' right to be credited for their ideas? This is not intended as a criticism of open data, the SPRINT Data Analysis Challenge, or similar systems/ventures, but is an effort to objectively note what may be remediable flaws in the worthwhile, growing and dynamic uses of open data. We offer preliminary analytics to shed more light and provide fodder for additional discussion.
Collapse
Affiliation(s)
- Nicholas W Carris
- University of South Florida, Taneja College of Pharmacy, Tampa, Florida, USA
| | - Byron Cheon
- University of South Florida, Morsani College of Medicine, Tampa, Florida, United States
| | - Jay Wolfson
- University of South Florida, College of Public Health, Tampa, Florida, United States
| |
Collapse
|
9
|
Jayasinghe S. Pharmaceutical industry sponsorship of academic conferences: ethics of conflict of interest. J Med Ethics 2020; 47:medethics-2020-106224. [PMID: 32703842 DOI: 10.1136/medethics-2020-106224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/23/2020] [Accepted: 05/31/2020] [Indexed: 06/11/2023]
Abstract
Sponsorship of medical conferences by the pharmaceutical industry has led to many ethical issues, especially in resource-poor developing countries. The core issue in these instances is to reduce or avoid conflicts of interests (COIs). COI is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by secondary interests. Disruption of social trust should also be considered. This deontological approach should be complemented by a consequentialist approach. Towards this, the concept of distal interests (DI) is introduced. DI lies beyond the immediately visible COIs and the consequences of immediate decisions. They are 'distal' in time or place: 'DI in time' means consequence of the decision in future scenarios, while 'DI in space' means those that impinge on other institutions or bodies. In judging the consequences, it is also necessary to consider the reality of the existing relationship between the pharmaceutical industry and organisers of conferences. In more developed countries, these relationships are governed by stricter regulations, adherence to codes of conduct by both parties and stronger institutional oversights. In contrast, developing countries such as Sri Lanka the regulatory environment is lax and the demarcation of interests between the pharmaceutical industry and the medical profession is considerably blurred. Therefore, establishing clear rules of engagement between the stakeholders should be considered as an attempt to clear the muddy waters. The paper proposes a set of guidelines to capture these approaches.
Collapse
Affiliation(s)
- Saroj Jayasinghe
- Department of Medical Humanities and Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo 00800, Sri Lanka
| |
Collapse
|
10
|
Mishra SC. A discussion on controversies and ethical dilemmas in prostate cancer screening. J Med Ethics 2020; 47:medethics-2019-105979. [PMID: 32631969 DOI: 10.1136/medethics-2019-105979] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/17/2020] [Accepted: 05/22/2020] [Indexed: 06/11/2023]
Abstract
Prostate cancer (PCa) is one of the the most common cancers in men. A blood test called prostate-specific antigen (PSA) has a potential to pick up this cancer very early and is used for screening of this disease. However, screening for prostate cancer is a matter of debate. Level 1 evidence from randomised controlled trials suggests a reduction in cancer-specific mortality from PCa screening. However, there could be an associated impact on quality of life due to a high proportion of overdiagnosis and overtreatment as part of the screening. The US Preventive Services Task Force (USPSTF) in 2012 recommended that PSA-based PCa screening should not to be offered at any age. However, considering the current evidence, USPSTF recently revised its recommendation to offer the PSA test to men aged 55-69 years with shared decision-making, in line with earlier guidelines from the American Cancer Society and the American Urological Association. A shared decision making is necessary since the PSA test could potentially harm an individual. However, the literature suggests that clinicians often neglect a discussion on this issue before ordering the test. This narrative discusses the main controversies regarding PCa screening including the PSA threshold for biopsy, the concept of overdiagnosis and overtreatment, the practical difficulties of active surveillance, the current level 1 evidence on the mortality benefit of screening, and the associated pitfalls. It offers a detailed discussion on the ethics involved in the PSA test and highlights the barriers to shared decision-making and possible solutions.
Collapse
Affiliation(s)
- Satish Chandra Mishra
- Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, Bhabha Atomic Research Centre Hospital, Mumbai, MH 400094, India
| |
Collapse
|
11
|
Abstract
This is an invited submission from the Editor-in-Chief as the introductory piece for an 'Ethics Roundtable'. This piece will include invited commentaries from experts in surgical education, medical ethics, law and the prospective body donor perspective.
Collapse
Affiliation(s)
- Hannah James
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Trauma & Orthopaedic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
12
|
Walker TA, James HK. Use of cadavers to train surgeons: what are the ethical issues? - body donor perspective. J Med Ethics 2020; 46:476. [PMID: 32102836 DOI: 10.1136/medethics-2019-105998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 06/10/2023]
Affiliation(s)
- Tracy A Walker
- Anatomy Administrator & Registered body donor, School of Medicine, Keele University, Staffordshire, UK
| | - Hannah K James
- Clinical Trials Unit, University of Warwick, Coventry, UK
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
13
|
Slowther AM. Use of cadavers to train surgeons: respect for donors should remain the guiding principle. J Med Ethics 2020; 46:472-473. [PMID: 32029543 DOI: 10.1136/medethics-2019-105995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/26/2020] [Indexed: 06/10/2023]
Affiliation(s)
- Anne Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
14
|
Frush BW, Malone JR. Suffering and the moral orientation of presence: lessons from Nazi medicine for the contemporary medical trainee. J Med Ethics 2020; 47:medethics-2020-106061. [PMID: 32332152 DOI: 10.1136/medethics-2020-106061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 06/11/2023]
Abstract
Medical trainees should learn from the actions of Nazi physicians to inform a more just contemporary practice by examining the subtle assumptions, or moral orientations, that led to such heinous actions. One important moral orientation that still informs contemporary medical practice is the moral orientation of elimination in response to suffering patients. We propose that the moral orientation of presence, described by theologian Stanley Hauerwas, provides a more fitting response to suffering patients, in spite of the significant barriers to enacting such a moral orientation for contemporary trainees.
Collapse
Affiliation(s)
- Benjamin Wade Frush
- Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jay R Malone
- Department of Pediatrics and Critical Care Medicine, Washington University in St Louis, St Louis, Missouri, USA
| |
Collapse
|
15
|
Corfield L, Williams RA, Lavelle C, Latcham N, Talash K, Machin L. Prepared for practice? UK Foundation doctors' confidence in dealing with ethical issues in the workplace. J Med Ethics 2020; 47:medethics-2019-105961. [PMID: 32277020 DOI: 10.1136/medethics-2019-105961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/13/2020] [Accepted: 03/20/2020] [Indexed: 06/11/2023]
Abstract
This paper investigates the medical law and ethics (MEL) learning needs of Foundation doctors (FYs) by means of a national survey developed in association with key stakeholders including the General Medical Council and Health Education England. Four hundred sevnty-nine doctors completed the survey. The average self-reported level of preparation in MEL was 63%. When asked to rate how confident they felt in approaching three cases of increasing ethical complexity, more FYs were fully confident in the more complex cases than in the more standard case. There was no apparent relationship with confidence and reported teaching at medical school. The less confident doctors were no more likely to ask for further teaching on the topic than the confident doctors. This suggests that FYs can be vulnerable when facing ethical decisions by being underprepared, not recognising their lack of ability to make a reasoned decision or by being overconfident. Educators need to be aware of this and provide practical MEL training based on trainee experiences and real-world ethics and challenge learners' views. Given the complexities of many ethical decisions, preparedness should not be seen as the ability to make a difficult decision but rather a recognition that such cases are difficult, that doubt is permissible and the solution may well be beyond the relatively inexperienced doctor. Educators and supervisors should therefore be ensuring that this is clear to their trainees. This necessitates an environment in which questions can be asked and uncertainty raised with the expectation of a supportive response.
Collapse
Affiliation(s)
| | | | - Claire Lavelle
- GP Trainee, Wirral GP Specialty Training Scheme, Birkenhead, UK
| | - Natalie Latcham
- Department of Medicine, Morecambe Bay Hospitals NHS Trust, Kendal, Cumbria, UK
| | - Khojasta Talash
- Academic Foundation Doctor, Morecambe Bay Hospitals NHS Trust, Kendal, Cumbria, UK
| | - Laura Machin
- School of Health and Medicine, Lancaster University, Lancaster, Lancashire, UK
| |
Collapse
|
16
|
Lokugamage AU, Ahillan T, Pathberiya SDC. Decolonising ideas of healing in medical education. J Med Ethics 2020; 46:265-272. [PMID: 32029542 DOI: 10.1136/medethics-2019-105866] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/25/2019] [Accepted: 11/28/2019] [Indexed: 05/28/2023]
Abstract
The legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity. In response to the increased interest in social justice, medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations. This paper aims to explore decolonising ideas of healing within medical education following recent events including the University College London Medical School's Decolonising the Medical Curriculum public engagement event, the Wellcome Collection's Ayurvedic Man: Encounters with Indian Medicine exhibition and its symposium on Decolonising Health, SOAS University of London's Applying a Decolonial Lens to Research Structures, Norms and Practices in Higher Education Institutions and University College London Anthropology Department's Flourishing Diversity Series. We investigate implications of 'recentring' displaced indigenous healing systems, medical pluralism and highlight the concept of cultural humility in medical training, which while challenging, may benefit patients. From a global health perspective, climate change debates and associated civil protests around the issues resonate with indigenous ideas of planetary health, which focus on the harmonious interconnection of the planet, the environment and human beings. Finally, we look further at its implications in clinical practice, addressing the background of inequality in healthcare among the BAME (Black, Asian and minority ethnic) populations, intersectionality and an increasing recognition of the role of inter-generational trauma originating from the legacy of slavery. By analysing these theories and conversations that challenge the biomedical view of health, we conclude that encouraging healthcare educators and professionals to adopt a 'decolonising attitude' can address the complex power imbalances in health and further improve person-centred care.
Collapse
Affiliation(s)
- Amali U Lokugamage
- Clinical and Professional Practice, University College London Medical School, London, UK
- Women's Health, Whittington Health NHS Trust, London, UK
| | | | | |
Collapse
|
17
|
Marcus D, Simone A, Block L. Design thinking in medical ethics education. J Med Ethics 2020; 46:282-284. [PMID: 32054776 DOI: 10.1136/medethics-2019-105989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/19/2020] [Accepted: 01/27/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Design thinking (DT) is a tool for generating and exploring ideas from multiple stakeholders. We used DT principles to introduce students to the ethical implications of organ transplantation. Students applied DT principles to propose solutions to maximise social justice in liver transplant allocation. METHODS A 150 min interactive workshop was integrated into the longitudinal ethics curriculum. Following a group didactic on challenges of organ donation in the USA supplemented by patient stories, teams of students considered alternative solutions to optimise fairness of organ distribution and ethical implications of changing the current model. Facilitators led students through DT steps of empathy, defining the team's point of view, ideating on potential solutions, prototyping a specific idea and testing the idea through oral presentation, with questions and answers by peers and faculty. The curriculum was evaluated with presurveys and postsurveys including quantitative and open-ended items. RESULTS 100 first year medical students participated. Before the session, 75.3% of students had no practical experience with DT. Following participation, students reported an increased understanding of the current liver transplant allocation system (p<0.01) and an increased appreciation of shortcomings of the current organ allocation system (p<0.01). After the session, 73.8% of students felt that DT could be used to approach complex health system problems. DISCUSSION Students participating in a DT workshop displayed improved knowledge and attitudes toward organ transplantation and DT. In this pilot study, DT showed promise as a student-led approach emphasising collaboration and creativity in ethics curricula in medical education.
Collapse
Affiliation(s)
- David Marcus
- Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| | - Amanda Simone
- Medicine, Allina Healthcare, Minneapolis, Minnesota, USA
| | - Lauren Block
- Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| |
Collapse
|
18
|
Pascual-Ramos V, Contreras-Yáñez I, Arce Salinas CA, Saavedra Salinas MA, Del Mercado MVDM, López Zepeda J, Muñoz López S, Vázquez-Mellado J, Amezcua Guerra LM, Fragoso Loyo HE, Villarreal Alarcón MA, Pérez Cristobal M, Rubio Pérez EN, Torres Jiménez AR, Maldonado MDR, Álvarez-Hernández E. Evaluation of medical ethics competencies in rheumatology: local experience during national accreditation process. J Med Ethics 2019; 45:839-842. [PMID: 31604831 DOI: 10.1136/medethics-2019-105717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/18/2019] [Accepted: 09/26/2019] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Rheumatologists are the primary healthcare professionals responsible for patients with rheumatic diseases and should acquire medical ethical competencies, such as the informed consent process (ICP). The objective clinical structured examination is a valuable tool for assessing clinical competencies. We report the performance of 90 rheumatologist trainees participating in a station designed to evaluate the ICP during the 2018 and 2019 national accreditations. METHODS The station was validated and represented a medical encounter in which the rheumatologist informed a patient with systemic lupus erythematosus with clinically active nephritis about renal biopsy. A trained patient-actor and an evaluator were instructed to assess ICP skills (with a focus on kidney biopsy benefits, how the biopsy is done and potential complications) in obtaining formal informed consent, delivering bad news and overall communication with patients. The evaluator used a tailored checklist and form. RESULTS Candidate performance varied with ICP content and was superior for potential benefit information (achieved by 98.9% of the candidates) but significantly reduced for potential complications (37.8%) and biopsy description (42.2%). Only 17.8% of the candidates mentioned the legal perspective of ICP. Death (as a potential complication) was omitted by the majority of the candidates (93.3%); after the patient-actor challenged candidates, only 57.1% of them gave a clear and positive answer. Evaluators frequently rated candidate communications skills as superior (≥80%), but ≥1 negative aspect was identified in 69% of the candidates. CONCLUSIONS Ethical competencies are mandatory for professional rheumatologists. It seems necessary to include an ethics competency framework in the curriculum throughout the rheumatology residency.
Collapse
Affiliation(s)
- Virginia Pascual-Ramos
- Immunology and Rheumatology, Instituto Nacional de Ciencia Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Irazú Contreras-Yáñez
- Immunology and Rheumatology, Instituto Nacional de Ciencia Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | | | | | | | | | | | | | | | - María Del Rocio Maldonado
- Department of Internal Medecine, Rheumatology Unit, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | | |
Collapse
|
19
|
Finlay IG, Choong KA, Nimmagadda SR. Is UNESCO's Undergraduate Bioethics Integrated Curriculum (Medical) fit for purpose? J Med Ethics 2019; 45:600-603. [PMID: 31253639 DOI: 10.1136/medethics-2019-105437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/21/2019] [Accepted: 06/13/2019] [Indexed: 06/09/2023]
Abstract
In 2017, UNESCO introduced an Undergraduate Bioethics Integrated Curriculum to be taught in Indian medical schools, with an implied suggestion that it could subsequently be rolled out to medical schools in UNESCO's other member states. Its stated aim is to create ethical awareness from an early stage of a doctor's training by infusing ethics instructions throughout the entire undergraduate medical syllabus. There are advantages to a standardised integrated curriculum where none existed. However, the curriculum as presently drafted risks failing to achieve its laudable aims. There are important lessons to be drawn from UNESCO's First Syllabus for Youth Bioethics Education (2018), which is aimed at schoolchildren and teenagers, and represents a creative, effective and culturally sensitive way to teach bioethics.
Collapse
Affiliation(s)
- Ilora G Finlay
- House of Lords, London, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Kartina A Choong
- Lancashire Law School, University of Central Lancashire, Preston, UK
| | | |
Collapse
|
20
|
Svantesson M, de Snoo-Trimp JC, Ursin G, de Vet HCW, Brinchmann BS, Molewijk B. Important outcomes of moral case deliberation: a Euro-MCD field survey of healthcare professionals' priorities. J Med Ethics 2019; 45:608-616. [PMID: 31320403 PMCID: PMC6817990 DOI: 10.1136/medethics-2018-104745] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND There is a lack of empirical research regarding the outcomes of such clinical ethics support methods as moral case deliberation (MCD). Empirical research in how healthcare professionals perceive potential outcomes is needed in order to evaluate the value and effectiveness of ethics support; and help to design future outcomes research. The aim was to use the European Moral Case Deliberation Outcome Instrument (Euro-MCD) instrument to examine the importance of various MCD outcomes, according to healthcare professionals, prior to participation. METHODS A North European field survey among healthcare professionals drawn from 73 workplaces in a variety of healthcare settings in the Netherlands, Norway and Sweden. The Euro-MCD instrument was used. RESULTS All outcomes regarding the domains of moral reflexivity, moral attitude, emotional support, collaboration, impact at organisational level and concrete results, were perceived as very or quite important by 76%-97% of the 703 respondents. Outcomes regarding collaboration and concrete results were perceived as most important. Outcomes assessed as least important were mostly about moral attitude. 'Better interactions with patient/family' emerged as a new domain from the qualitative analysis. Dutch respondents perceived most of the outcomes as significantly less important than the Scandinavians, especially regarding emotional support. Furthermore, men, those who were younger, and physician-respondents scored most of the outcomes as statistically significantly less important compared with the other respondents. CONCLUSIONS The findings indicate a need for a broad instrument such as the Euro-MCD. Outcomes related to better interactions between professionals and patients must also be included in the future. The empirical findings raise the normative question of whether outcomes that were perceived as less important, such as moral reflexivity and moral attitude outcomes, should still be included. In the future, a combination of empirical findings (practice) and normative reflection (theories) will contribute to the revision of the instrument.
Collapse
Affiliation(s)
- Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Janine C de Snoo-Trimp
- Department of Medical Humanities, VU Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Göril Ursin
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Henrica CW de Vet
- Department of Epidemiology and Biostatistics, VU Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | - Bert Molewijk
- Department of Medical Humanities, VU Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| |
Collapse
|
21
|
Cohen N. Is it just semantics? Medical students and their 'first patients'. J Med Ethics 2019; 45:411-414. [PMID: 30826735 DOI: 10.1136/medethics-2017-104306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 06/09/2023]
Abstract
There have been multiple factors involved in the decline of the anatomy course's central role in medical education over the last century. The course has undergone a multitude of changes, in large part due to the rise in technology and cultural shifts away from physical dissection. This paper argues that, as the desire of medical schools to introduce clinical experiences earlier in the curriculum increased, anatomy courses began implementing changes that would align themselves with the shifting culture towards incorporating humanistic values early on in the medical curriculum. One of these changes, argued as a product of this shift, included calling a cadaver a 'patient' and introducing the cadaver as a student's 'first patient'. This change has been seen in different universities and textbooks. This paper argues that the use of the words 'patient' to describe the cadaver in order to promote principled habits in medical students may in fact create an environment that does the opposite. By equating an environment in which the subject of dissection is lifeless and incapable of participation, and the space is discouraging of emotions and conducive to untested coping mechanisms to the clinical environment through using the word 'patient', values like detached concern, a controversial practice in medicine, can be implicitly encouraged. An ethical analysis of the use of the word 'patient' to describe the cadaver shows that this practice can promote unethical habits in students and that changing this aspect of anatomy lab culture could improve ethical dispositions of future physicians.
Collapse
Affiliation(s)
- Natalie Cohen
- Medical School, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| |
Collapse
|
22
|
Abstract
In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion's share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners' capacity to think through difficult ethical decisions in daily clinical practice.
Collapse
Affiliation(s)
- Melanie Jansen
- Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law, Children’s Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Peter Ellerton
- Faculty of Humanities and Social Sciences, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
23
|
DuBroff JJ. Wearing humanism on your sleeve. J Med Ethics 2018; 44:646-647. [PMID: 28887359 DOI: 10.1136/medethics-2016-103905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/02/2017] [Accepted: 07/11/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Jason J DuBroff
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| |
Collapse
|
24
|
Groothuizen JE, Callwood A, Gallagher A. NHS constitution values for values-based recruitment: a virtue ethics perspective. J Med Ethics 2018; 44:518-523. [PMID: 29773610 DOI: 10.1136/medethics-2017-104503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 03/25/2018] [Accepted: 04/28/2018] [Indexed: 06/08/2023]
Abstract
Values-based recruitment is used in England to select healthcare staff, trainees and students on the basis that their values align with those stated in the Constitution of the UK National Health Service (NHS). However, it is unclear whether the extensive body of existing literature within the field of moral philosophy was taken into account when developing these values. Although most values have a long historical tradition, a tendency to assume that they have just been invented, and to approach them uncritically, exists within the healthcare sector. Reflection is necessary. We are of the opinion that selected virtue ethics writings, which are underpinned by historical literature as well as practical analysis of the healthcare professions, provide a helpful framework for evaluation of the NHS Constitution values, to determine whether gaps exist and improvements can be made. Based on this evaluation, we argue that the definitions of certain NHS Constitution values are ambiguous. In addition to this, we argue that 'integrity' and 'practical wisdom', two important concepts in the virtue ethics literature, are not sufficiently represented within the NHS Constitution values. We believe that the NHS Constitution values could be strengthened by providing clearer definitions, and by integrating 'integrity' and 'practical wisdom'. This will benefit values-based recruitment strategies. Should healthcare policy-makers in other countries wish to develop a similar values-based recruitment framework, we advise that they proceed reflectively, and take previously published virtue ethics literature into consideration.
Collapse
Affiliation(s)
- Johanna Elise Groothuizen
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Alison Callwood
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Ann Gallagher
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| |
Collapse
|
25
|
Abstract
Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts.
Collapse
|